Use of Robots for Hysterectomy Soars, but with Little Benefit

Action Points

Note that this large retrospective cohort study demonstrated similar complication rates between laparoscopic and robotic hysterectomy.

Be aware that residual confounding may have biased the results; if sicker patients are offered robotic hysterectomy, a true benefit to the technology may not be detected in this observational framework.

Robotically assisted hysterectomy increased dramatically from 2007 to 2010, despite higher cost and similar complication rates compared with laparoscopic procedures, a review of data from more than 400 hospitals showed.

Robotically assisted procedures accounted for 0.5% of hysterectomies in 2007 and almost 10% of procedures in 2010. At hospitals offering robotic hysterectomy, the approach accounted for more than 20% of all hysterectomies, according to Jason Wright, MD, of Columbia University in New York City, and co-authors.

The growth of robotic hysterectomy volume occurred despite a lack of data to support any advantages over conventional laparoscopic hysterectomy, the investigators reported in the Feb. 20 issue of JAMA.

"Our population-based analysis suggests that, despite limited data, the use of robotically assisted hysterectomy for benign gynecologic disease increased substantially over a 3-year period," they wrote in their commentary on the findings.

"The introduction of robotic-assisted hysterectomy was paralleled by a decrease in the rate of abdominal hysterectomy, both in hospitals where robotic-assisted hysterectomy was performed and in those where robotic procedures were not performed."

"Our study indicates that, while robotic assistance was associated with increased use of minimally invasive surgery for hysterectomy, when compared with laparoscopic hysterectomy, the robotic procedure offers little short-term benefit and is accompanied by significantly higher costs," they added.

Little Evidence of Superiority

Robotically assisted surgery has several potential benefits that have driven interest in and use of the technology since the FDA approved the surgical platform in 2005. Among the possible benefits, robotic systems offer a wider range of motion with instrumentation and three-dimensional stereoscopic visualization. Users can work from an ergonomically friendly console.

In contrast to certain other surgical procedures, notably radical prostatectomy, several minimally invasive alternatives to open surgery have been developed. Laparoscopic and vaginal hysterectomy have established roles and have been studied extensively. Robotic hysterectomy has gained support in the gynecologic surgery community despite supporting evidence that has come primarily from small observational studies, the authors noted in their introduction.

Proponents of robotic hysterectomy have asserted that the approach extends minimally invasive surgery to women who otherwise would undergo laparotomy, the authors continued. Such claims, as well as purported advantages versus conventional laparoscopic surgery, have little supporting evidence.

Large Database Analyzed

To examine the state of robotic hysterectomy, Wright and co-authors queried a large, all-payer database comprising patient records from more than 600 acute-care hospitals in the U.S. The authors identified women 18 and older who underwent hysterectomy from 2007 through the first quarter of 2010. On the basis of ICD-9 codes, investigators determined the type of hysterectomy performed in each case.

The authors extracted information about hospital characteristics, patient demographics and clinical characteristics, complications, and costs. Study objectives included determining the uptake of robotic hysterectomy, complication rates associated with different approaches to hysterectomy, and costs of different types of hysterectomy.

The study included 264,758 women who underwent hysterectomy at 441 hospitals. The study population comprised 123,288 (46.7%) women who underwent abdominal hysterectomy, 54,912 (20.7%) who had vaginal hysterectomies, 75,761 (28.6%) who had laparoscopic procedures, and 10,797 (4.1%) who underwent robotically assisted hysterectomy.

The results showed that use of robotically assisted hysterectomy and laparoscopic hysterectomy increased during the study period. Robotic hysterectomy's share of total hysterectomy volume at the hospitals increased from <1% at the start of the study period to 9.5% at the end. Conventional laparoscopy accounted for 24.3% of hysterectomies in 2007 to 30.5% by the end of the study period.

The authors noted that uptake of laparoscopic hysterectomy has occurred slowly, given that the technique has been available since the 1990s. By comparison, uptake of robotic hysterectomy has been rapid.

At hospitals offering robotic hysterectomy, the approach accounted for 22.4% of all hysterectomies. The rate of vaginal hysterectomy declined from 21.7% to 19.8%, and abdominal hysterectomy's share of the procedural volume declined from 53.6% to 40.1%. Use of vaginal and abdominal hysterectomy decreased at hospitals with and without robotic surgical systems.

Complication Rates Similar

Investigators performed a propensity-matched analysis of 4,971 patients who underwent robotic hysterectomy and 4,971 who underwent laparoscopic hysterectomy. The analysis yielded complication rates of 5.5% with robotic hysterectomy and 5.3% with laparoscopic procedures. Significantly fewer patients required hospitalization for more than 2 days after robotic hysterectomy (19.6% versus 24.9%, RR 0.78, 95% CI 0.67 to 0.92).

Transfusion requirements and rates of discharge to nursing facilities did not differ between patients who had robotically assisted or laparoscopic hysterectomy.

Laparoscopic hysterectomy was associated with a median total cost of $6,679 per case, as compared with $8,868 per case for robotically assisted hysterectomy. The $2,189 higher cost of robotic hysterectomy included $962 more for fixed costs and $1,207 more for variable costs.

The study left several key questions without answers, according to the authors of an accompanying editorial. Robotic surgery might have a shorter learning curve, enabling physicians to offer minimally invasive surgery to their patients. On the other hand, surgical training is expensive.

"Would it be a better use of resources to train more surgeons in laparoscopic techniques than to spend the money on more robot machines?" asked Joel S. Weissman, PhD, and Michael Zinner, MD, of Brigham & Women's Hospital in Boston.

A second unanswered question relates to whether as-yet unidentified subgroups of patients might derive specific benefits from robotic surgery. Finally, the article did not address the commercialization of the technology and the impact of direct-to-consumer advertising on commercialization.

"In the absence of additional research or decreases in price, the path taken by the medical and payer community should be one of caution," Weissman and Zinner concluded.

The study was supported by the National Cancer Institute.

The authors of the article and the editorial had no relevant disclosures.

Reviewed by F. Perry Wilson, MD, MSCE Instructor of Medicine, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner

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